Oral Appliance Wars… The Empire Must Strike Back!

Many of us grew up following the Star Wars franchise. Looks like we’re about to witness this all over again…

This past year we have been introduced to a new way of viewing appliances that manage Sleep Apnea; the 3-D Printer way. Upon first seeing the “New World” NARVALTM by RESMED, I thought it looked flimsy and unsubstantial. Boy was I wrong. Further due diligence and actual hands–on experience set me straight. From both an efficacy and patient experience point of view, the NARVALTM has surprised both me, and others. It is a lightweight, sleek, attractive, durable appliance that intrudes very minimally on tongue space, and it comes with a 3-year warranty on breakage. Of course, this helps to make up for the fact that it is made of a non-reparable (but durable) nylon polymer.

NARVALTM by RESMED

Personally, I still very much like the “Old World” Herbst appliance (especially the one made by Gergens lab in Arizona). However, by now, we have all learned that there is no perfect offering in the appliance world; only appliances with pros and cons. The Herbst offers superior lateral movement due to the telescoping advancement mechanism it employs, as opposed to the fixed nylon strap used in the NARVALTM. It also allows advancement in much smaller increments; the NARVALTM being limited to 1 mm incremental advancements. Often, but not always, patient’s that have insufficient dentition to obtain adequate retention with a NARVALTM can be managed with a Herbst appliance. Finally, labs don’t usually provide longer than a 1-year warranty on breakage for a Herbst, but if they do break, they are reparable and I have found them to be very robust appliances if made well. So, “Old World” vs “New World” still remains a tie in my mind.

Herbst by Gergens Lab, Arizona, USA

Now comes the interesting part; there is a “New Kid on the Block” in the “New World” arena. Yet to be FDA approved (which should be a cinch due to equivalency rules, ETA is sometime in 2014), the PantheraTM by Panthera Dental, Quebec, Canada. Upon first viewing the NARVALTM and PantheraTM side by side, they seem practically identical. However, closer inspection differentiates them. It appears that the PantheraTM is a more evolved NARVALTM. Perhaps there is a story to be told here? 

PantheraTM by Panthera Dental, Quebec, Canada

First, the similarities. Both devices are manufactured by a 3-D printer, are made of a nylon polymer, are lightweight, engage the teeth in a similar manner and advance the mandible by replacing nylon straps; of varying length.

Now, the differences. Both can be advanced in 1mm increments, although I am told that the PantheraTM is acquiring the ability to be advanced in 0.5 mm increments sometime in 2014. This enhancement may qualify the PantheraTM for PDAC and CMS reimbursement in the US when the time comes.  The Straps on the PantheraTM are beefier for enhanced strength, intended to reduce the chance of stretching for heavy bruxers, have larger, easier to read labels and have an enhanced Patent Pending locking mechanism, making it impossible for the strap to dislodge while being worn. The PantheraTM people have moved the section attaching the mandibular posterior segments from the facial to the lingual of the lower anterior teeth, due to some patients complaining about tissue irritation with advancement. As a further comfort enhancement, the wing with the strap attachment does not protrude buccally as much on the PantheraTM, also intended to reduce tissue irritation. When dealing with teeth that you want to protect, the PantheraTM allows you to isolate a tooth or teeth from being incorporated into the retention. The strap attaching mandibular and maxillary components together runs parallel to the occlusal plain for both devices, intended to be gentler on the TMJ. However, The PantheraTM software ensures that occlusal contact is anterior, in the canine area. In contrast, the NARVALTM sometimes has heavy posterior contact requiring chair-side adjustment. Finally, the PantheraTM people say that there is less tissue coverage with their device and that it has a smoother finish, both of which I had difficulty observing.

Oh, one more difference, the NARVALTM comes with a 3-year breakage warranty vs a 5-year breakage warranty for the PantheraTM.

It will be interesting to observe RESMED’s answer to the PantheraTM enhancements. After all, THE EMPIRE MUST STRIKE BACK! Let the 3-D printers roll…

John Viviano BSc DDS D ABDSM